Analysis Life-saving Equipment and Survival The vessel did not carry any of the life-saving equipment specified in the regulations. When the operator and his helper were thrown into the water, they had no means other than the vessel's portable gas tanks to provide flotation. The operator was fortunate in that his gas tank provided enough buoyancy to keep him afloat, particularly as it was determined that he was experiencing the symptoms of hypothermia by the time he was rescued. Had the operator or his helper had access to an approved lifejacket, not only would the lifejacket have provided sufficient flotation, the whistle attached to the lifejacket could have provided the means to attract the attention of the accompanying vessel. Similarly, a flare or the use of a portable radio could have been used to attract attention. Buddy System Fishermen who use the buddy system benefit when the intervals between checking on each other are appropriate for the existing conditions. It appears that buddy system response made in this instance was not made in sufficient time to assist the accompanying fishing vessel crew, before loss of life occurred. There were no procedures or guidelines to follow with respect to the buddy system, to look out for one another. Working in pairs, within sight of each other, has obvious safety benefits and the buddy system most likely has been successful in the past for preventing loss of life. If the operator and his helper had been fishing alone, it is most likely that the operator would also have succumbed to either hypothermia and/or drowning. It is also very likely that the buddy system creates an increased level of comfort. Situational Awareness Although, it was initially indicated that the seacock was closed, later information received indicated that it had been opened while the vessel was under way to allow the venturi effect to help drain the bilge water from the boat. It was not closed while retrieving the nets so the stern was gradually filling with water. With both crewmembers working forward, water aft could not be seen due to the fish crates and the motion of the vessel in the seas would not have made it obvious. Furthermore, the operator of the occurrence vessel apparently did not have sufficient skill-based knowledge to recognize the dangers inherent in continuing to harvest fish while shipping water. No action was taken to lighten the vessel by discharging the crates of fish as the vessel was losing its remaining reserve buoyancy. Given the deteriorating weather conditions, and that the owner of the vessels (who was the only experienced person there) was on-scene, it would have been prudent of him to suspend fishing and order both vessels back to port. For about 15 to 20 minutes, the owner and his helper, who were in the other vessel and preoccupied with fishing, were unaware of the disappearance of the occurrence vessel. The outcome of this insufficient level of situational awareness was that the necessary safety precautions with regard to weather and fishing conditions were not taken. Self-enforcement - Small Fishing Vessel Inspection Regulations TC has not maintained a large enough presence to make an impact on the local fishing community, particularly with respect to promoting awareness of the requirement to carry life-saving and safety equipment. Given the level of the TC presence, the applicable regulations become essentially self-enforced. However, copies of the regulations are not readily available locally from TC or through local fishermen's organizations. In addition, there does not appear to be an adequate audit mechanism in place at TC to monitor compliance. The result is that many vessel owners are unaware of the minimum safety equipment requirements. Regulations made pursuant to the Canada Shipping Act can be enforced by the RCMP, only after the Minister of Transport has invited the RCMP to do so. The Gimli detachment of the RCMP had not been formally approached by Transport Canada, Marine Safety to enforce the relevant sections affecting commercial fishing vessels. Vessel Loading and Shipping of Water The fishermen involved in this occurrence did not have the necessary knowledge or experience to conduct a safe operation and they continued to load the vessel, in deteriorating weather conditions, until it was swamped. Loss of Buoyancy Those working forward, at the horn, could not see how much water had accumulated at the stern due to the open seacock and shipped water, because fish crates obstructed the view aft. The water shipped over the bow from the second large wave ran aft and its weight caused the vessel to further trim by the stern, markedly reducing the remaining reserve buoyancy to the point where the vessel downflooded and quickly sank by the stern. The vessel had been taking water through the seacock which trimmed the boat by stern and was swamped by two large cresting waves and sank quickly by the stern. When both fishermen were working at the bow they could not see the amount of water accumulating aft, due to the positioning of fish crates between them and the stern. Neither fisherman was wearing a lifejacket, nor was there any other life-saving equipment aboard the vessel. The distressed fishermen in the water did not have a means, radio, mechanical or pyrotechnic, of calling for assistance and their cries for help were not heard on the accompanying vessel. The helper drowned because he was not wearing a lifejacket.Findings as to Causes and Contributing Factors The vessel had been taking water through the seacock which trimmed the boat by stern and was swamped by two large cresting waves and sank quickly by the stern. When both fishermen were working at the bow they could not see the amount of water accumulating aft, due to the positioning of fish crates between them and the stern. Neither fisherman was wearing a lifejacket, nor was there any other life-saving equipment aboard the vessel. The distressed fishermen in the water did not have a means, radio, mechanical or pyrotechnic, of calling for assistance and their cries for help were not heard on the accompanying vessel. The helper drowned because he was not wearing a lifejacket. Although there are several hundred small commercial fishing vessels operating on Lake Winnipeg, despite joint RCMP and CCG water safety patrols, there has been little or no enforcement of the life-saving equipment requirements of the Small Fishing Vessel Inspection Regulations in recent years. There is a general lack of safety consciousness amongst the local fishermen and vessel owners, and few if any have requested from TC either information, an inspection, or a safety equipment audit. Dissemination and/or availability of information, in the form of literature or pamphlets, with respect to the statutory life-saving equipment requirements, has been very limited in the Lake Winnipeg area. There are no safe loading criteria, or literature, available.Findings as to Risk Although there are several hundred small commercial fishing vessels operating on Lake Winnipeg, despite joint RCMP and CCG water safety patrols, there has been little or no enforcement of the life-saving equipment requirements of the Small Fishing Vessel Inspection Regulations in recent years. There is a general lack of safety consciousness amongst the local fishermen and vessel owners, and few if any have requested from TC either information, an inspection, or a safety equipment audit. Dissemination and/or availability of information, in the form of literature or pamphlets, with respect to the statutory life-saving equipment requirements, has been very limited in the Lake Winnipeg area. There are no safe loading criteria, or literature, available. The operator survived by holding on to a partially filled gas tank.Other Findings The operator survived by holding on to a partially filled gas tank. Safety Action Action Taken Transport Canada Transport Canada, Marine Safety, Prairie and Northern Region has been re-organized with a resultant increase in staffing levels. Because of the large area covered by the Region, and the relatively small number of inspectors, it was decided to amalgamate activities with respect to small fishing vessels (under 15 gross tons), and other small commercial vessels below the size requiring an annual inspection. Inspectors will visit communities where small commercial fishing vessels operate and apprise operators of the requirements of the regulations and information on safety. The Region will be better able to deliver the applicable monitoring and inspection programs, and will commence an integrated program, including a communication strategy, to get the message out to all persons involved in small commercial vessel operations in the Region. Owner The owner's boats are now reportedly equipped with safety equipment, including bilge pump, marine radio and inflatable flotation vests. Province of Manitoba The Fisheries Branch, Manitoba Conservation, is cooperating with Transport Canada, Marine Safety by providing access to information on their files such that TC is better able to access fishers in the area and also to attend and participate in fisheries meetings held by the Province. Other initiatives are also being contemplated to mitigate fishing vessel accidents.